No surprise for direct P2Y12 inhibitor versus older prodrug.

Action Points

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

SAN DIEGO -- Ticagrelor (Brilinta) dropped platelet reactivity lower sooner when given on the table for patients going directly to revascularization after diagnostic angiography, a pharmacodynamics study affirmed.

Platelet reactivity dropped further in the first 2 hours after dosing at the start of percutaneous coronary intervention (PCI) with a standard 180 mg dose of ticagrelor (Brilinta) than with 600 mg clopidogrel (Plavix, -194.7 versus-123.5 PRU, P<0.001), Roxana Mehran, MD, of Mount Sinai Hospital in New York City, and colleagues found.

The proportion of patients with high platelet reactivity on drug showed a similar pattern: 81.8% versus 97.7% at the end of PCI (P=0.030) and 2.4% versus 53.3% at 8 hours (P<0.001).

While the findings were expected based on healthy-volunteer studies, it was important to confirm in a sicker population, Mehran told reporters at an SCAI press conference, calling the findings "reassuring."

The real question is how would ticagrelor stack up against other agents coming down the pipeline like cangrelor, suggested co-moderator Gregg Stone, MD, of Columbia University Medical Center/New York Presbyterian Hospital in New York City.

"Everyone is thinking to themselves 'What are the clinical applications of these data?'," he said. "We naively think that, of course, it's all the periprocedural events which start in cath lab. As soon as you rupture the plaque, you blow up the balloon, you further activate platelets, especially in biomarker negative patients who have lower baseline platelet activation."

Ticagrelor still doesn't cover the first 30 minutes of what is typically an hour-long procedure, he noted.

However, the two haven't been directly compared so it's not clear whether there are clinical implications to the time-onset difference, Mehran said, calling for such a prospective study.

The other question is "how cost-effective is it to apply that across the board, especially now with the new data with crush tablets, which is in the label of ticagrelor," she said. "We just have no idea. With the increased surface area, you might get a much better absorption with those patients."

Her multicenter study included 100 low-risk, troponin-negative acute coronary syndrome patients undergoing ad-hoc PCI, which is the route more than half of such patients go in current U.S. practice for elective procedures. Patients were randomly assigned to open-label treatment with one of the two drugs.

The study wasn't powered for clinical endpoints and didn't show any difference in major adverse cardiovascular events between treatments. Mehran deferred to the PLATO trial's comparison on hard outcomes.

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